A new adhesive technique for microvascular anastomoses: A preliminary report

for Microvascular Report

Department

of Maxilla-facial

Surgery

and Plastic

Surgery,

University

of Jena,

Jena,

G.D.R.

Summary--A new technique is presented for the anastomosis of microvessels, using only a tissue adhesive (Fibrinkleber, Human-lmmuno”, produced by lmmuno A. G. Vienna) without sutures. The feasibility of this technique is demonstrated experimentally on the femoral artery and vein

in rats.

suture used in microvascular inflict considerable d:lmage on the X\WI \vall, much effort ha> been spent in developing methods of anastomosis in which the ntlmbct- of sutures is reduced to a minimum (H~~S~CIII ,111d Blumenxtock. 1964: I-auritzcn. 1(,7X). !\cc~~rdin5g 10 Ijinges 01 I//. ( 1978). ;I cclmbined >uturc-adhesive technique. using fihrino_ccn adhchi\c. is a safe and effective method but c\cn I~I,, procedure requires at least two sutura. The present study was designed to investigate the feasibility of Loscular end-to-end anastomosis llsillg fibrinc~gcrl adhesive material only (F-ibrlnhleber HLIIIUII Immune” ) and dispensing with the IIW 01’ any permanent sutures. Since

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Materials

ma_v

and Experimental

undiaturbcd the blood circulation epigastric vase15 (Fig. I ).

throu$’

the

FEMORAL ARTERY

FEMORAL

EPIGASTRIC

VEIN

ANASTOMOSIS

method

l‘hc adhesive material used consists of two comp~~ncnts. the lyophilised fibrinogen adhesive WLi the lynphiliscd thrombin-Calcium. The l‘ihrino~en .Idhesi\e is dissolved in sterile water 1; Ir injcclion al 37 C‘ and the thrombin-c~llciuln cIlIaride i, also dissol\,ed in sterile water for injccti~~n did Aprotinin at room temperature according IO the maker’s instructions. The :tdhc\ive t~hniyuc wxs lesled on IO ft~nrai ;IrIcrics :~nd II) veins in 5 male albino U istar rals. \\eirhin g iOOg to 45Og. Both vessels \\,cre mobiliscd from the level of the inguinal ligament 10 the origin of the @gastric vessels. double-ligated distal to the epigastric branches and divided bct\vecn the ligatures. The femoral ai-tcr\ and \,cin wet-c then divided below the insuinal ligment tcj provide a site for the experimental microvascular anastomosis leaving

After approximation without tension of the cut ends of the vessels two [J-shaped hutureh (10 (1. BV 4 Ethicon) were inserted ;II a11 ~nglc ~4’ IX0 used by Ho
62

Fig. 2 Approximation temporary stay sutures solutions.

BRITISH

of the cut before dropping

JOURNAL

OF

PLASTIC

SURGERY

vessel ends with 2 on the tissue adhesive

Fig. 3 After dropping on the tissue adhesive solutions the cut vessel ends are “telescoped” by tightening the temporary stay sutures.

and the anastomosis completed Fig. 4 Telescopic microclamps have been removed. The tension on the stay sutures has been relaxed before removal of the sutures.

Fig. 5 Longitudinal section of the femoral artery to show the site of adhesions 14 days after telescopic anastomosis. Collagenous connective tissue and neointima of smooth muscle cells can be seen between the retracted vessel ends (arrow), The adventitia shows pronounced vascularisation. The letter L indicates the lumen of the artery.

other (Figs. 1,3). It was never necessary to dilate the recipient vessel. Depending on the direction of blood flow the proximal segment of the artery was inserted into the distal one and the cut end of the distal vein segment into the proximal one. This manoeuvre was easier in the artery than in

the vein. The suture ends were held tight for approximately 4 to 5 minutes until the fibrinogen coagulated. The microvascular clamps were then but the anastomosis was left removed undisturbed for some minutes (Fig. 4). If the vessel ends remained in their original position the

A NEW

ADHESIVE

TECHNIQUE

FOR

MICROVASCULAR

ANASTOMOSES

6.1

retaining sutures were cut short and removed. As a general rule the length of the telescoping vascular segment was about 1.5 times the diameter of the vessel.

microvascular anastomosis using a two-suture technique. Further studies will be made to investigate the applications of the fibrinogen adhesive technique in clinical practice.

Results

References

The patency of the anastomosed vessels was checked visually after reopening the skin incision 24 or 48 hours after operation and histologically after 14 days (Fig. 5). All 10 anastomosed arteries were patent, but only 8 of the 10 veins.

Dinges, H. P., Matras, H., Kletter, G. and Chiari, F. (1978). Histo-pathologische Untersuchungen zum Hcilungsverlauf bei Anwendung de!“o” MikrogefGsanastomosen kombinierten Naht- und Klebetechnik. c’usu 7, 161. Hoshein, D. J. and Blumenstock, D. A. (1964). Anasiomosl:5 of small arteries using tissue adhesive. Sur,~erl~. C;rww~~log~~ clrld Ohsfrtric.s, 118, 112. Law&en, C. (1978). A new and easier way to anastomost: mlcrovessels. An experimental study in Irats ,%rrntii~~u~itrr~ Jourwl I,/ Phtic ud Reconstructiw Surp~r~. 12. 291.

Discussion

study of microvascular end-to-end Our anastomosis in rats using fibrinogen adhesive shows that the vessel union is solid provided there is telescoping of one cut vessel segment into the other to increase significantly the total adhesive area. With this procedure the narrowing of the vascular lumen at the site of anastomosis might be considered a disadvantage possibly increasing the risk of haemodynamic disorders. However Lauritzen (1978) reported no sign of in series of thrombosis his telescopic

The

Authors

P.

Karl, MD, Department of Maxlllo-facial Surgery and Plastic Surgery. University of Jena. A. Tilgner, MD, Department of Maxilla-l‘acial Sur_re~-y and Plastic Surgery. University of Jena. Professor H. Heiner. Dlrector of the Department of Maxillofacial Surgery and Plastic Surgery, University of Jew. Requests for reprints to: Dr SC. med. P. Karl, Department of Maxilla-faclal Surgery and Plastic Surgery. Friedrich-SchillerUniversitat. 18,Bachstrasse. 69, Jena, CDR.